Abutaher M. Yahia

Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study.

OBJECTIVE We prospectively evaluated the safety and effectiveness of aggressive mechanical disruption of clot in conjunction with intra-arterial administration of a low-dose third-generation thrombolytic agent (reteplase) to treat ischemic stroke in patients who were considered poor candidates for intravenous alteplase therapy or who failed to improve after intravenous thrombolysis. Mechanical clot disruption was used if low-dose pharmacological thrombolysis was ineffective. This strategy was adopted to increase the recanalization rate without increasing the risk of intracerebral hemorrhage. METHODS Patients were considered poor candidates for intravenous therapy because of severity of neurological deficits, interval from symptom onset to presentation of at least 3 hours, or recent major surgery. We administered a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. After the initial doses were administered, we performed mechanical angioplasty (for proximal occlusion) or snare manipulation (for distal occlusion) at the occlusion site if recanalization had not occurred. The remaining doses of thrombolytics were subsequently administered if required for further recanalization. Angiographic responses were graded using modified Thrombolysis in Myocardial Infarction (TIMI) criteria. Clinical evaluations were performed before and 24 hours, 7 to 10 days, and 1 to 3 months after treatment. RESULTS Nineteen consecutive patients were treated (mean age, 64.3 ± 16.2 yr; 10 were men). Initial National Institutes of Health Stroke Scale scores ranged from 11 to 42. Time from onset to treatment ranged from 1 to 9 hours. Occlusion sites were in the following arteries: cervical internal carotid (n = 7), intracranial internal carotid (n = 1), middle cerebral (n = 9), and basilar (n = 2). Of the 19 patients, thrombolysis alone was used in 5 patients, angioplasty was performed in 11 patients, and snare maneuvers were used in 5 patients. Complete restoration of blood flow (modified TIMI Grade 4) was observed in 12 patients, near-complete restoration of flow (modified TIMI Grade 3) in 4 patients, minimal response (modified TIMI Grade 1) in 1 patient, and no response in 2 patients (modified TIMI Grade 0). Neurological improvement at 24 hours (decline of at least 4 points in National Institutes of Health Stroke Scale score) was observed in seven patients. Five other patients experienced further improvement in National Institutes of Health Stroke Scale score at 7 to 10 days. No vessel rupture, dissection, or symptomatic intracranial hemorrhages were observed. At the time of follow-up evaluation, 7 of 19 patients were functionally independent. CONCLUSION A high rate of recanalization and clinical improvement can be observed in patients with ischemic stroke using low-dose thrombolytic agents with adjunctive mechanical disruption of clot. Moreover, this strategy may reduce the risk of intracerebral hemorrhage observed with thrombolytics.

Prognostic significance of hypernatremia and hyponatremia among patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE Abnormal serum sodium levels (hyponatremia and hypernatremia) are frequently observed during the acute period after aneurysmal subarachnoid hemorrhage (SAH) and may worsen cerebral edema and mass effect. We performed this study to determine the prognostic significance of serum sodium concentration abnormalities. METHODS We analyzed prospectively collected data for the placebo treatment group in a clinical trial conducted at 54 neurosurgical centers in North America. The presence of hypernatremia (serum sodium concentration of >145 mmol/L) and hyponatremia (serum sodium concentration of <135 mmol/L) was determined with serum sodium measurements obtained at admission and 3, 6, and 9 days after SAH. The effects of hypernatremia and hyponatremia on the risk of symptomatic vasospasm and on 3-month outcomes were analyzed after adjustment for the following potential confounding factors: age, sex, preexisting hypertension, admission Glasgow Coma Scale score, initial mean arterial pressure, subarachnoid clot thickness, intraventricular blood or intraparenchymal hematoma, ventricular dilation, and aneurysm size and location. RESULTS Of 298 patients in the analysis, 58 (19%) developed hypernatremia and 88 (30%) developed hyponatremia. Hypernatremia was significantly associated with poor outcomes (odds ratio, 2.7; 95% confidence interval, 1.2–6.1). A positive correlation was observed between the highest sodium values recorded and Glasgow Outcome Scale scores at 3 months (P < 0.0001 by analysis of variance). Hyponatremia was not associated with 3-month outcomes (odds ratio, 1.9; 95% confidence interval, 0.9–4.3). Neither hypernatremia nor hyponatremia was associated with the risk of symptomatic vasospasm. CONCLUSION Hyponatremia seems to be more common than hypernatremia after SAH. However, hypernatremia after SAH is independently associated with poor outcomes, and this association is independent of previously identified outcome predictors, including age and admission Glasgow Coma Scale scores. Further studies are needed to define the underlying mechanism of this association.

A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage

The authors performed a multicenter prospective observational study to evaluate the feasibility and safety of intravenous antihypertensive protocol for acute hypertension in patients with intracerebral hemorrhage (ICH). Twentyseven patients with ICH and acute hypertension (mean age 61.37 ± 14.27; 10 were men) were treated to maintain the systolic blood pressure (BP) below 160 mm Hg and diastolic BP below 90 mm Hg within 24 hours of symptom onset. Neurological deterioration (defined as a decrease in initial Glasgow Coma Scale score= 2) was observed in 2 (7.4%) of 27 patients during treatment. Among patients who underwent follow-up computed tomography, hematoma expansion (more than 33% increase in hematoma size at 24 hours) was observed in 2 (9.1%) of 22 patients. Patients treated within 6 hours of symptom onset were more likely to be functionally independent (modified Rankin scale–= 2) at 1 month compared with patients who were treated between 6 and 24 hours (8 of 18 versus 0 of 9,P= .03). Aggressive pharmacological treatment of acute hypertension in patients with ICH can be initiated early with a low rate of neurological deterioration and hematoma expansion.

Plasma exchange versus intravenous immunoglobulin treatment in myasthenic crisis

Article abstract We performed a retrospective multicenter chart review to compare the efficacy and tolerance of plasma exchange (PE) and intravenous immunoglobulin (IVIg) in treatment of 54 episodes of myasthenic crisis. After adjustment for other variables, PE (compared with IVIg) was associated with a superior ventilatory status at 2 weeks (partial F = 6.2, p = 0.02) and 1 month functional outcome (partial F = 4.5, p = 0.04). However, the complication rate was higher with PE compared with IVIg (13 versus 5 episodes, p = 0.07).

Timing of neurologic deterioration in massive middle cerebral artery infarction: A multicenter review

ObjectiveTo determine the time interval between symptom onset and neurologic deterioration related to cerebral edema in patients with massive middle cerebral artery infarction. The time period between onset and neurologic deterioration represents the window for surgical intervention. DesignMulticenter retrospective chart review. SettingsFive university-affiliated medical centers. PatientsFifty-three patients with massive middle cerebral artery infarction who experienced neurologic deterioration defined by a decrease in the Glasgow Coma Scale score of two or more points attributable to mass effect. Measurements and Main ResultsA total of 53 patients (mean age, 62 ± 18 yrs; 25 [47%] were men) with neurologic deterioration were identified by using International Classification of Diseases (9th revision) codes and local registries. Medical records and neuroimaging studies were reviewed by a stroke neurologist or neurointensivist to identify the time of neurologic deterioration. Thrombolytics were used at presentation in 19 (35%) patients. A total of 19 (36%) patients had neurologic deterioration within 24 hrs of symptom onset. By 48 hrs, 36 (68%) patients had manifested clinical deterioration. A few patients had later neurologic deterioration on day 3 (n = 10), day 4 (n = 2), day 5 (n = 2), and day 6 or after (n = 3). A total of 25 (47%) of the 53 patients died during hospitalization. The highest frequency of deaths occurred on day 3. ConclusionsNeurologic deteriorations related to cerebral edema after massive middle cerebral artery infarction occur in most patients within 48 hrs of symptom onset.

Risk factors for subarachnoid hemorrhage

OBJECTIVECigarette smoking has been demonstrated to increase the risk of subarachnoid hemorrhage (SAH). Whether cessation of smoking decreases this risk remains unclear. We performed a case-control study to examine the effect of smoking and other known risk factors for cerebrovascular disease on the risk of SAH. METHODSWe reviewed the medical records of all patients with a diagnosis of SAH (n = 323) admitted to Johns Hopkins Hospital between January 1990 and June 1997. Controls matched for age, sex, and ethnicity (n = 969) were selected from a nationally representative sample of the Third National Health and Nutrition Examination Survey. We determined the independent association between smoking (current and previous) and various cerebrovascular risk factors and SAH by use of multivariate logistic regression analysis. A separate analysis was performed to determine associated risk factors for aneurysmal SAH. RESULTSOf 323 patients admitted with SAH (mean age, 52.7 ± 14 yr; 93 were men), 173 (54%) were hypertensive, 149 (46%) were currently smoking, and 125 (39%) were previous smokers. In the multivariate analysis, both previous smoking (odds ratio [OR], 4.5; 95% confidence interval [CI], 3.1–6.5) and current smoking (OR, 5.2; 95% CI, 3.6–7.5) were significantly associated with SAH. Hypertension was also significantly associated with SAH (OR, 2.4; 95% CI, 1.8–3.1). The risk factors for 290 patients with aneurysmal SAH were similar and included hypertension (OR, 2.4; 95% CI, 1.8–3.2), previous smoking (OR, 4.1; 95% CI, 2.7–6.0), and current smoking (OR, 5.4; 95% CI, 3.7–7.8). CONCLUSIONHypertension and cigarette smoking increase the risk for development of SAH, as found in previous studies. However, the increased risk persists even after cessation of cigarette smoking, which suggests the importance of early abstinence from smoking.

Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature.

OBJECTIVE To determine the prevalence, clinical characteristics, and long-term outcomes in cases involving transient ischemic attacks (TIAs) or ischemic strokes secondary to embolization from unruptured intracranial aneurysms. METHODS We identified all available patients with intracranial aneurysms and ischemic strokes in three university-affiliated hospitals, using either International Classification of Diseases-9th Revision codes or local registries. Patients with clinically or radiologically detected cerebral infarctions distal to intracranial aneurysms, in the absence of other causes for the infarctions, were included. An aneurysmal embolic source was considered highly probable by the primary neurosurgeon/neurologist in all cases. Follow-up data for the patients were acquired through reviews of clinical visits or telephone interviews. A review of the literature was performed to identify characteristics of previously reported patients. RESULTS Ischemic strokes or TIAs attributable to embolization from the aneurysmal sac were observed for 9 of 269 patients (3.3%) with unruptured aneurysms. Of these nine patients, five were women and four were men (mean age, 62 yr; age range, 45-72 yr). Symptomatic aneurysms were located in the middle cerebral artery (n = 4), internal carotid artery (n = 3), posterior cerebral artery (n = 1), or vertebral artery (n = 1). The mean maximal diameter was 12.5 mm (range, 5-45 mm). Six patients underwent surgical treatment, of whom two experienced postoperative cerebral infarctions referable to the distribution of the artery harboring the aneurysm. Two patients were treated with aspirin, and one patient received no treatment. The mean follow-up period was 38 months (range, 1-60 mo). None of the patients experienced additional ischemic events during the follow-up period. Among the 41 previously reported patients, conservative treatment was used for 20 patients (mean follow-up period, 50.7 +/- 44.5 mo). Four of the 20 patients experienced recurrent TIAs, 1 patient experienced worsening of symptoms, and 1 patient died during the follow-up period. A total of 21 patients underwent surgical treatment (mean follow-up period, 33.6 +/- 32.3 mo). Of these patients, only one experienced recurrent TIAs. Two patients experienced postoperative seizures, and one patient died during the follow-up period. All recurrent symptoms with either surgical or conservative treatment were transient, and no patient experienced a major or disabling stroke during the follow-up period. CONCLUSION Ischemic events can occur distal to both small and large unruptured intracranial aneurysms (predominantly in the anterior circulation). The long-term risk of recurrent ischemic events, particularly major or disabling strokes, seems to be low with either surgical or conservative treatment.

Early predictors of outcome in patients receiving hypervolemic and hypertensive therapy for symptomatic vasospasm after subarachnoid hemorrhage

Objective: Symptomatic vasospasm after subarachnoid hemorrhage (SAH) is associated with a high incidence of permanent disability and death. For early identification of patients who are at risk for poor outcome, we determined the predictors of outcome in patients with symptomatic vasospasm after SAH. Design: We retrospectively determined the prognostic value of clinical characteristics and computed tomographic scan both at admission and at the time of initiation of hypervolemic and hypertensive therapy. Settings: Neurosciences critical care unit at a University hospital. Patients: A total of 70 consecutive patients who developed symptomatic vasospasm after SAH. Intervention: Treatment with oral nimodipine, hypervolemic therapy, and hypertensive therapy. Angioplasty and intra‐arterial papaverine were used in patients with vasospasm resistant to standard treatment. Measurements and Main Results: Poor outcome, defined as Glasgow Outcome Scale Score of 3‐5 at 2 months or discharge, was observed in 32 (46%) patients. In the logistic regression analysis, a Glasgow Coma Scale (GCS) score of ≤11 (odds ratio, 11.0; 95% confidence interval, 3.6‐39.3) and hydrocephalus (odds ratio, 4.3; 95% confidence interval, 1.2‐18.2) at the time of initiation of hypervolemic and hypertensive therapy were significantly associated with poor outcome. Poor outcome was observed in 91% of the patients who had both a GCS score of ≤11 and hydrocephalus compared with 15% of patients with a GCS score of >11 and no hydrocephalus at the time of initiation of hypervolemic and hypertensive therapy. A GCS score of ≤11 was also independently associated with length of intensive care unit stay (F ratio = 18.0; p = .0011) and hospital stay (F ratio = 9.2; p = .0034) after initiation of hypervolemic and hypertensive therapy. Conclusions: The results of this study suggest that outcome in patients with symptomatic vasospasm can be effectively predicted by routinely available information, including GCS score at the time of initiation of hypervolemic and hypertensive therapy. This information can be used for selection and stratification of patients in future treatment studies of patients with symptomatic vasospasm.

Outcome following intracerebral hemorrhage and subarachnoid hemorrhage.

Abstract Intracerebral hemorrhage and subarachnoid hemorrhage account for almost 20% of all stroke cases. Both forms of stroke are associated with a high morbidity and mortality rate. The incidence of intracerebral hemorrhage increases with the age and certain ethnical groups are more affected. Subarachnoid hemorrhage tends to occur in a much younger population than other types of strokes. Outcome predictors for intracerebral and subarachnoid hemorrhage have been extensively discussed in the literature. Based on the current literature, we review the morbidity and mortality rates and predictors of outcome for these two life-threatening diseases. Initial Glasgow Coma Scale (GCS) score, hematoma volume, and presence of ventricular blood are the most prominent predictors of outcome following intracerebral hemorrhage. Age and initial severity of neurologic deficits on presentation, measured by GCS, Hunt and Hess Scale or the World Federation of Neurological Surgeons Scale, are the most important predictors of outcome following subarachnoid hemorrhage. [Neurol Res 2002; 24: S58-S62]

Neuroimaging of stroke: a review.

Advances in neuroimaging technology during the past 30 years have resulted in a virtual explosion in the amount of pathologic information that can be obtained in the clinical stroke setting. This neuroimaging revolution has led to a much better understanding of cerebrovascular and tissue pathology, creating a wide array of opportunities for acute treatment and secondary prevention. Advances include early and accurate detection of ischemic and infarcted tissue and the ability to reveal hypoperfused tissue at risk. Clinicians are increasingly able to noninvasively detect embolic and atherothrombotic intravascular lesions. Vascular lesions associated with stroke can be characterized through endovascular neuroimaging techniques and repaired by various means. In this article, we provide an overview and update on the various techniques used in the neuroimaging of stroke and intracranial hemorrhage, including computed tomography, magnetic resonance imaging, ultrasound, and catheter angiography. We outline the specific role of each modality in clinical practice.